1/03/2010 @ 12:01AM

Coordinating Care

In December a 67-year-old patient of mine with diabetes and heart failure was discharged from a hospital in Brooklyn after a bad bout of pneumonia. Though I was in periodic touch with the doctors at the hospital, I didn’t have access to her medical records, and when she returned to see me she brought me a handwritten note scrawled by the hospital discharge nurse. This note listed two medications for her diabetes and one for her heart that she had never taken before. I didn’t know the circumstances of why the new medications had been added. I also didn’t know why the pills I’d been giving her previously had been stopped (or if they had). Not only that, but the antibiotic she was taking for her pneumonia was listed without any indication as to dose or duration.

It took me more than an hour on the phone, via e-mail and at the fax machine, interacting with the other doctors and nurses involved, to piece together exactly what had happened to my poor patient. The time I spent doing this was emotionally rewarding because it helped her, but it wasn’t reimbursable, and I believe that it should be. Consider that this process took time away from the care of my other patients. This process is necessary, but I believe doctors performing this service should be paid at least at a rate commensurate with an extended office visit (more than $75) for the service.

As the U.S. Congress moves towards combining the Senate and House bills and enacting health reform legislation, there will likely be bundling of payments to hospitals based on quality of outcome, expedient discharges and decreased readmissions. Though this new focus on quality may provide needed incentives for hospitals, at the same time it is important that a doctor’s role in coordinating outpatient care of patients with chronic diseases–like asthma, chronic obstructive pulmonary disease and congestive heart failure–not be excluded. We also need funding mechanisms to support this type of care integration.

Continuity must occur not only when a patient is admitted or discharged from the hospital, but on an ongoing basis. Chronic diseases are labor-intensive, and the work involved goes well beyond simple service. Reimbursements to doctors should reflect time spent helping the patient.

There is a precedent for this idea. In 2000, Congress mandated that the Center for Medicare and Medicaid Services conduct the Physician Group Practice Demonstration to investigate the effectiveness of a hybrid system of payments to physicians, which would combine fee-for-service with bonuses for quality care. In February 2008 the U.S. General Accounting Office released a study on coordinating inpatient and outpatient Medicare services, which concluded that “care coordination programs show promise in achieving cost savings and improving patient outcomes for Medicare beneficiaries.” Strategies were developed for coordinating care for high-risk and high-cost patients, including those with congestive heart failure and diabetes.

According to the GAO, the major limitation in implementing the program was a delay in payment and feedback to physicians, problems that will have to be addressed if such a program is to be implemented nationally. Going forward, it will also be crucial that such a program be well regulated, with every service well documented, so that the program doesn’t take on a life of its own. The documentation required must be user-friendly, so that physicians don’t spend more time filling out paperwork than the service is worth.

Beginning with Medicare and Medicaid, and hopefully extending to include private plans as well, provisions for outpatient incentives and payments should become part of the routine practice of medicine. The focus should be on rewarding doctors and nurses as well as the institutions who attempt to consolidate and coordinate care–simplifying and refining medication and patient problem lists to make sure they are accurate and up to date.

An emphasis on coordinated care will lead to billions of dollars in saved health care dollars by decreasing duplication. It will also cut down on medical errors–the Institute of Medicine has estimated that over 100,000 deaths occur yearly in the U.S. due to mistakes–and help the patient greatly. If I knew right away how long my pneumonia patient was supposed to be taking her antibiotics, it not only would have saved me several fumbling phone calls and records requests, but would have also decreased the chance of my under- or overtreating her ailment.

Integrated systems both inside and outside the hospital may be facilitated by conversion to electronic medical records, where instant access to information will help reconcile different treatments prescribed by different doctors.

Including incentives and directives for coordinated systems of care into the routine practice of medicine will help patients, reward hospitals and doctors for good behavior, and streamline the medical process in a way that is good for all.

Marc Siegel, M.D. is an associate professor of medicine and Medical Director of Doctor Radio at NYU Langone Medical Center. He is a Fox News Medical Contributor.